ARDS is a multifactorial syndrome that causes significant morbidity and mortality in infants and children. |
The BD can evaluate the severity of ARDS in children as shown by the decreased survival and reduced number of ventilation-free days in patients with severe ARDS compared with patients with mild and moderate ARDS. |
Negative trial data have been published on the use of surfactants in infants/children with ARDS but it is important to evaluate every aspect of the selected treatment. |
ARDS in infants and children is different from hyaline membrane disease—in children, as well as an underlying surfactant deficiency, there is inhibition/inactivation of endogenous surfactant. In these patients, removal of inhibitors should be performed before administration of exogenous surfactant. |
The type of lung damage first needs to be established: exogenous surfactant therapy is useful in patients with direct lung injury. |
BAL with normal saline and surfactant may show a synergistic therapeutic effect that allows the removal of inhaled material, the recruitment of non-ventilating areas and the maintenance of surfactant pool size. BAL using a diluted surfactant solution followed by supplementation of exogenous surfactant with regular instillation has been effectively adopted in clinical trials. |
The timing, dosage and type of surfactant used are of paramount importance. The earlier treatment is begun the greater the chance of a positive outcome. |
There are reliable real-world data showing poroctant alfa is effective and well tolerated in children/infants with ARDS. |
1 Introduction
2 Defining Acute Respiratory Distress Syndrome (ARDS)
3 Berlin Definition of ARDS Validated for Adults: But What About Infants and Children?
4 Incidence of ARDS
5 Mechanism of Surfactant Deficiency in ARDS
6 Surfactant: The Solution to This Now Well-Defined Problem?
Study | Patients (N) | Disease or syndrome | Surfactant | Outcomes |
---|---|---|---|---|
Fettah et al. [48] | Baby (1) | ARDS secondary to near drowning | Curosurf®
| Rapid and persistent improvement after 2 doses of Curosurf® (100 mg/kg body weight, 1.25 ml/kg) |
Willson et al. [45] | Children (110 enrolled) | ARDS | Infasurf®
| No immediate improvement in oxygenation: study stopped at sponsor’s request |
Willson et al. [34] | Children (152) | ARDS from multiple causes | Infasurf®
| Improved oxygenation and ventilation |
Moller et al [38] | Children (35) | ARDS, multiple causes | Alveofact®
| Improved oxygenation |
Hermon et al. [36] | Children (19) | ARDS + post-op cardiac | Curosurf® or Alveofact®
| Improved oxygenation |
Herting et al. [37] | Children (8) | Pneumonia | Curosurf®
| Improved oxygenation |
Infants (20 and 40) | RSV bronchiolitis | Curosurf®
| Improved oxygenation | |
Tibby et al. [47] | Infants (19) | Respiratory syncytial virus bronchiolitis | Survanta®
| More rapid improvement in oxygenation and ventilation indices over the first 60 h of ventilation |
Lopez-Herce et al. [35] | Children (20) | ARDS + post-op cardiac | Curosurf®
| Improved oxygenation |
Children (29 and 42) | ARDS from multiple causes | Infasurf®
| Improved oxygenation | |
Findlay et al. [43] | Infants (40) | Meconium aspiration | Survanta®
| Improved oxygenation decreased pneumothorax and mechanical ventilation |
Infants (28 and 328) | ECMO, multiple indications | Survanta®
| Improved oxygenation, decreased ECMO | |
Khammash et al. [42] | Infants (20) | Meconium aspiration syndrome | bLES®
| Improved oxygenation in 75% of patients |
7 How to Explain this Dichotomy: What Should We be Doing in the Clinic?
Possible mechanism | Possible solution |
---|---|
sPLA2 inactivation | Use of surfactant refractory to sPLA2 inactivation |
Failure to remove PARDS triggers | Adoption of anti-inflammatory agents, antibiotics, anti-viral therapy |
Lack of knowledge of effective dose/lavage ratio | Modification of ratio based on BAL studies |
Lack of knowledge of effective dose | Modification of dose |
Lack of knowledge of effective procedure | Use of bronchoscope and bronchoalveolar lavage |
Composition of surfactant | Use of more effective one |
Wrong timing | Start earlier the treatment |
Poor ventilated lung areas | Lung recruitment by ventilation, bronchial toilette, prone position |